SOAR- RN

1. SOAR- RN Alissa Lyon, LCSW- Meridian Emergency Dept. Social Worker OreanaHarless, LCSW- Boise Emergency Dept. Social Worker

2. Mental Health Overview What do you hope to gain from today’s training? What is your experience with mental illness? What training did you receive in Nursing School pertaining to mental health?

3. An estimated 26.2 percent of Americans ages 18 and older — about one in four adults — suffer from a diagnosable mental disorder in a given year. • When applied to the 2004 U.S. Census residential population estimate for ages 18 and older, this figure translates to 57.7 million people. • Mental disorders are the leading cause of disability in the U.S. and Canada. • Nearly half (45 percent) of those with any mental disorder meet criteria for 2 or more disorders, with severity strongly related to comorbidity. Statistics

4. Axis I (Clinical Disorders): Depression, Bipolar Disorder, Anxiety, Schizophrenia • Axis II (Personality Disorders): Borderline, Antisocial, Dependent, Histrionic

5. Persistent sad, anxious, or “empty” mood • Feelings of hopelessness or pessimism • Feelings of guilt, worthlessness, or helplessness • Loss of interest or pleasure in hobbies and activities that were once enjoyable, including sex • Significant weight fluctuation or change in appetite • Decreased energy, fatigue; feeling “slowed down” Depression

6. Difficulty concentrating, remembering, or making decisions • Trouble sleeping, early morning awakening, or oversleeping • Restlessness or irritability • Persistent physical symptoms, such as headaches, digestive disorders, and chronic pain that do not respond to routine treatment Depression (Cont.)

8. Postpartum depression is a period of time of extreme vulnerability to depression shortly after giving birth.  • “Postpartum blues” occur in about 80% of women. • PPD affects 12 to 15% of women. Postpartum Depression

9. Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Bipolar Disorder

10. Manic Mood Depressed Mood • A long period of feeling "high," or an overly happy or outgoing mood • Extremely irritable mood, agitation, feeling "jumpy" or "wired“ • A long period of feeling worried or empty • Loss of interest in activities once enjoyed, including sex Bipolar-Mood Changes

11. Manic Phase Depressed Phase • Talking fast, jumping from one idea to another, having racing thoughts • Being easily distracted • Increase in goal-directed activities • Being restless, sleeping little • Having an unrealistic belief in one's abilities • Spending sprees, impulsive sex, and impulsive business investments • Feeling tired or "slowed down" • Having problems concentrating, remembering, and making decisions • Being restless or irritable • Changing eating, sleeping, or other habits • Thinking of death or suicide, or attempting suicide Bipolar Disorder- Behavioral Changes

12. Anxiety is a complex combination of the feeling of fear, apprehension and worry often accompanied by physical sensations such as palpitations, chest pain and/or shortness of breath. • Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults. • About 18% of American adults have anxiety disorders. Anxiety Disorders

13. GAD is an anxiety disorder characterized by chronic anxiety, exaggerated worry and tension, even when there is little or nothing to provoke it. • Worries are accompanied by physical symptoms, especially fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, and hot flashes. Generalized Anxiety Disorder (GAD)

15. OCD is an anxiety disorder and is characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions). Obsessions often have themes to them, such as: • Fear of contamination or dirt • Having things orderly and symmetrical • Aggressive or horrific impulses • Sexual images or thoughts Obsessive-Compulsive Disorder

16. Fear of being contaminated by shaking hands or by touching objects others have touched • Doubts that you've locked the door or turned off the stove • Thoughts that you've hurt someone in a traffic accident • Intense distress when objects aren't orderly or facing the right way • Images of hurting your child • Avoidance of situations that can trigger obsessions, such as shaking hands • Replaying pornographic images in your mind • Dermatitis because of frequent hand washing • Skin lesions because of picking at your skin • Hair loss or bald spots because of hair pulling OCD-Symptoms of Obsessions

17. Compulsions typically have themes such as: • Washing and cleaning • Counting/ Checking • Demanding reassurances • Performing the same action repeatedly • Orderliness

18. Hand washing until your skin becomes raw • Checking doors repeatedly to make sure they're locked • Checking the stove repeatedly to make sure it's off • Counting in certain patterns • Making sure all your canned goods face the same way OCD-Symptoms of Compulsions

19. Panic disorder is an anxiety disorder and is characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress. Panic Disorder

20. Post-Traumatic Stress Disorder is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. • Traumatic events that may trigger PTSD include violent personal assaults, rape, sexual molestation, natural or human-caused disasters, accidents, or military combat.  PTSD

21. People with social phobia have a persistent, intense, and chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions. • Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, trembling, nausea, and difficulty talking. Social Anxiety

22. Schizophrenia and Psychosis - What's the Difference? • Psychosis is a general term used to describe psychotic symptoms. Schizophrenia is a kind of psychosis. • Several different brain disorders can lead to psychotic symptoms, including lesions in the brain resulting from head traumas, strokes, tumors, infections or the use of illegal drugs. • Physical testing can rule out medical conditions (seizure disorders, metabolic disorders, thyroid dysfunction, brain tumor, street drug use, etc) that sometimes have similar symptoms. • If a serious depression goes untreated for a long time, psychotic symptoms may develop. Psychotic Disorders

23. Schizophrenia Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves. The person finds it difficult to tell the difference between real and imagined experiences, to think logically, to express feelings, or to behave appropriately. • Symptoms may include the following: hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior, social withdrawal, lack of interest and poor hygiene.

24. Approximately 2.4 million American adults, or about 1.1 percent of the population age 18 and older in a given year,have schizophrenia. • Schizophrenia affects men and women with equal frequency. • Schizophrenia often first appears in men in their late teens or early twenties. In contrast, women are generally affected in their twenties or early thirties.

25. Characteristic Symptoms: Paranoid delusions, or delusions of persecution, for example believing that people are "out to get" you Delusions of reference - when things in the environment seem to be directly related to you even though they are not. Somatic delusions- false beliefs about your body Delusions of grandeur - for example when you believe that you are very special or have special powers or abilities. Hallucinations- Seeingor hearing things that don't exist, although hallucinations can be in any of the senses.

26. Thought disorder. Difficulty speaking and organizing thoughts may result in stopping speech midsentence or putting together meaningless words, sometimes known as "word salad." Disorganized behavior. This may show in a number of ways, ranging from childlike silliness to unpredictable agitation. Negative symptoms include flat or and emotion (blunted affect), poverty of speech (alogia), inability to experience pleasure (anhedonia), lack of desire to form relationships (asociality), and lack of motivation (avolition).

27. Schizoaffective Disorder- Symptoms that meet the criteria for Schizophrenia are present and during which, at some time, there is either a Major Depressive Episode, or a Mixed (Manic) Episode concurrent with symptoms of schizophrenia.Delusional Disorder- Non-bizarre delusions involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by a spouse or lover or having a disease.

28. Eating Disorders

29. Anorexia nervosa is a chronic and severe disorder with a high incidence of morbidity and mortality (Gowers et al, 2000). Signs and symptoms to look out for include: -Weight loss-Refusal to eat-Appetite loss-Fear of becoming obese-Self-induced vomiting-Difficulty in swallowing-Use or abuse of laxatives-Constipation-Preoccupation with food, weight loss and/or body image -Lack of menstruation Anorexia Nervosa

30. Physical problems that stem from the condition- some of which can become life threatening- include electrolyte imbalance, bradycardia, hypotension, hypothermia, fatigue, oedema and amenorrhoea. • It is essential to observe patients' nutritional status as eating disorders can be life threatening. • It is essential to monitor patients' elimination pattern as excessive use of diuretics and laxatives is common among patients with eating disorders. • Monitoring skin condition for breakdown and poor healing is an important part of the nurse's role.

31. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: • eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances • a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) Bulimia Nervosa

32. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. • The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. • Self-evaluation is unduly influenced by body shape and weight. • The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

33. Eating Disorders and Pregnancy • Magnifies eating disorder issues- weight and body concerns • Complications- miscarriage, premature • Increased risk for postpartum depression

34. You’re the best doctor in the world…no one understands me like you…What…no Norco!?? I hate you…You’re just like all the other terrible doctors! Personality Disorders

35. People with personality disorders tend to have: • Great difficulty getting along with others • History of disruptive relationships • Difficulty regulating feelings/ behavior • Difficulty learning from experience • Inability to accept responsibility for their own behaviors/problems

36. Said another way: • Personality disorders are excessively rigid patterns of behavior or relating to others. • “In most of us by the age of 30, the character has set like plaster, and will never soften again” • William James

37. Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. • Originally thought to be at the "borderline" of psychosis, people with BPD suffer from a disorder of emotion regulation. • These patients tend to triangulate and divide staff. Borderline Personality Disorder

38. Anti-Social Personality Disorder • Antisocial personality disorder is characterized by an individual's disregard for social rules and cultural norms, impulsive behavior, and indifference to the rights and feelings of others. • Approximately 1.0 percent of people aged 18 or over have antisocial personality disorder.

39. Dependent personality disorder is described as a pervasive and excessive need to be taken care of that leads to a submissive and clinging behavior as well as fears of separation. • The dependent and submissive behaviors are designed to elicit care giving and arise from a self-perception of being unable to function adequately without the help of others. Dependent Personality Disorder

40. The affected individual displays an enduring pattern of attention-seeking and excessively dramatic behaviors beginning in early adulthood and present across a broad range of situations. • Individuals with HPD are highly emotional, charming, energetic, manipulative, seductive, impulsive, erratic, and demanding. • “Extreme Drama Queen/King” Histrionic Personality Disorder

41. Dementia is a progressive decline in memory and at least one other cognitive area in an alert person.  These cognitive areas include attention, orientation, judgment, abstract thinking and personality.  Dementia symptoms vary depending on the cause, but common signs and symptoms include: • Memory loss • Difficulty communicating • Inability to learn or remember new information • Difficulty with planning and organizing • Difficulty with coordination and motor functions • Personality changes • Inability to reason • Inappropriate behavior • Paranoia • Agitation • Hallucinations Dementia

42. Dementia vs Delirium Delirium is an acute disorder of attention and global cognition (memory and perception) and is treatable.  The diagnosis is missed in more than 50% of cases.  The risk factors for delirium include age, pre-existing brain disease, and medications.  There are many causes, the most common are:D   DementiaE   Electrolyte disordersL   Lung, liver, heart, kidney, brainI    InfectionR   Rx DrugsI    Injury, Pain, StressU   Unfamiliar enviromentMMetobolic • Prevention of delirium includes the avoidance of psychoactive drugs, quiet environment, daytime activity, dark and quiet at night, visual and hearing assistive devices, orientation devices, and avoidance of restraints

43. What Causes Dementia? • Diseases that cause degeneration or loss of nerve cells in the brain such as Alzheimer's, Parkinson's and Huntington's. • Diseases that affect blood vessels, such as stroke, which can cause a disorder known as multi-infarct dementia. • Toxic reactions, like excessive alcohol or drug use. • Nutritional deficiencies, like vitamin B12 and folate deficiency.

44. Infections that affect the brain and spinal cord, such as AIDS dementia complex and Creutzfeldt-Jakob disease. Certain types of hydrocephalus that can result from developmental abnormalities, infections, injury, or brain tumors. Head injury -- either a single severe head injury or longer term smaller injuries, like in boxers. Illnesses other than in the brain, such as kidney, liver, and lung diseases, can all lead to dementia.

45. The Centers for Disease Control and Prevention recognized suicide as the 11th leading cause of death in the United States among all age groups in 2006. • This staggering number equates to 1 suicide every 16 minutes in the United States alone. Suicide Prevalence in the General Population

46. General hospital patients are estimated to have a suicide rate that is three times more than the “normal” population. • Roughly 4% of all completed suicides can be attributed to inpatient suicides. • The National Quality Forum has listed suicide or attempted suicide of a hospitalized patients as a “Never Event” meaning an event that is avoidable and therefore should never happen. Suicide in the Hospital

47. 1998: Suicide of hospitalized patients recognized as a reportable sentinel event • 2007: TJC established a National Patient Safety Goal aimed at identifying patients at risk for suicide and identifying safety risks that might be found within the hospital • 2008: TJC recognized a record number of inpatient suicides • 2009: Patient suicide ranked as the second most reported sentinel event

48. Suicide Risk Assessment What do you think is most important to assess suicide risk?

49. Actual attempt vs. verbalization • Method, planned out and means • Rescue was not self-initiated • History of suicide attempts • Previous psychiatric hospitalization(s) • Sense of hopelessness/helplessness • Command hallucinations Suicide Risk

50. SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric IllnessCo-morbidity Neurobiology Personality Disorder/Traits Impulsiveness Substance Use/Abuse Hopelessness Severe Medical Illness Suicide Family History Access To Weapons Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior